UPPER TRACT UC PRESENTATION.pptx

Upper tract urothelial cancer (sometimes called transitional cell carcinoma) is a cancer that occurs in either the inner lining of the tube that connects the kidney to the bladder (the ureter) or within the inner lining of the kidney.

1. Urology and Nephrology Center Mansoura, Egypt UNC Thursday meeting the 8 th FEB, 2024

2. Upper tract urothelial carcinoma ABDINUR JAMA Urology resident Urology and Nephrology Center Mansoura, Egypt

3. Introduction UTUC R efers to urothelial tumors that originate from the inner lining of the ureter, calyces, or renal pelvis .

4. EPIDEMIOLOGY Upper urinary tract carcinomas make up only 5% of the urothelial cancers. The highest incidence is observed in individuals age 70 to 90 years in the Balkan countries, where UTUC represents the 40% of all renal neoplasms. Multifocal presence of UTUC is diagnosed in 10% to 20% of cases. Concurrent bladder cancer is diagnosed in 17% of cases. UTUCs are twice as frequent in men than in women.

5. Risk factors Genetic predisposition Environmental factors tobacco exposure occupation analgesics chronic inflammation and infection arsenic

6. HISTOPATHOLOGY Urothelial carcinomas represent more than 90% of the upper urinary tract tumors. Pure non- urothelial upper urinary tract cancers are rare conditions. Variants of urothelial cancer are encountered in approximately 25% of UTUCs. Papillomas , inverted papillomas , and von Brunn nests are usually benign lesions .

7. UTUC develops through a gradual progression of hyperplasia to dysplasia and eventually carcinoma in situ (CIS) in a significant proportion of UTUC cases. CIS is difficult to diagnose with significant morphologic variations. The muscle invasion or invasion to the renal parenchyma or the surrounding adventitia is more likely to take place on the upper tract.

8. Clinical features Upper urinary tract tumors are associated with several symptoms and signs. The common symptoms include: Hematuria:(56-98%), dysuria, flank pain, which are usually related to localized disease. Advanced disease is characterized by flank or abdominal mass , weight loss, anorexia, and bone pain.

9. Diagnosis UTUCs are diagnosed using imaging, cystoscopy, urinary cytology and diagnostic ureteroscopy. Computed tomography urography has the highest diagnostic accuracy of the available imaging techniques.

10. Staging and grading systems The UICC 2017 TNM (Tumour, Node, Metastasis Classification) for the renal pelvis and ureter is used for staging (Table 1).

11. Table 1: TNM Classification 2017

12. N - Regional lymph nodes M - Distant metastasis

13. Table.2 :AJCC Staging System in Conjunction With the TNM System

14. Prognosis Invasive UTUCs usually have a very poor prognosis . The main factors to consider for risk stratification are listed in Figure 1.

15. Figure 1: Risk stratification of non-metastatic UTUC

16. Risk Stratification Tumor stage is difficult to assert based on the clinical criteria. The UTUC cases could be stratified between low- and high-risk tumors to distinguish the cases that are more appropriate for kidney-sparing treatment rather than radical surgery

17. Overall Survival of Patients With Upper Tract Urothelial Tumors (Renal Pelvis or Ureter) by Stage and Grade ( Campbell Walsh 12 th edition)

18. Disease management Localised disease Kidney-sparing surgery Kidney-sparing surgery for low-risk UTUC consists of surgery preserving the upper urinary renal unit and should be discussed in all low-risk tumours , irrespective of the status of the contralateral kidney.

19. Kidney-sparing surgery potentially allows avoiding the morbidity associated with open radical surgery without compromising oncological outcomes and kidney function .

20. Kidney-sparing surgery can also be considered in select patients with serious renal insufficiency or solitary kidney (i.e ., imperative indications).

21. High-risk non-metastatic disease Radical nephroureterectomy Open nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for high-risk UTUC, regardless of tumour location . Minimally-invasive approaches (i.e., pure laparoscopic and/or robot-assisted RNU) have shown oncologic equivalence in experienced hands.

22. Neoadjuvant chemotherapy has been associated with significant downstaging at surgery and ultimately survival benefit as compared to RNU alone.

23. Adjuvant chemotherapy was only associated with an overall survival benefit in patients with pure UC and the main limitation of using adjuvant chemotherapy for advanced UTUC remains the limited ability to deliver full dose cisplatin -based regimen after RNU, given that this surgical procedure is likely to impact renal function.

24. In patients with regional lymph node invasion who are cisplatin -unfit after RNU, induction chemotherapy with radiological evaluation and consolidating surgery is a treatment option.

25. A single post-operative dose of intravesical chemotherapy ( mitomycin C, pirarubicin ) 2–10 days after surgery reduces the risk of bladder tumour recurrence within the first years post-RNU .

26. Figure 2: Proposed flowchart for the management of UTUC

27. Figure 3: Surgical treatment according to location and risk status

28. 2.Metastatic disease Radical nephroureterectomy has no benefit in metastatic (M +) disease but may be used in palliative care. As UTUCs are urothelial tumours , platinum-based chemotherapy should provide similar results to those in bladder cancer.

29. Follow-up after initial treatment In all cases, there should be strict follow-up after radical management to detect metachronous bladder tumours , as well as invasive tumours , local recurrence and distant metastases .

30. When kidney-sparing surgery is performed, the ipsilateral upper urinary tract requires careful follow-up due to the high risk of recurrence.

31. Thank you